Acute aortic dissection is a fatal disease if early diagnosis and institution of appropriate therapy are delayed. Unfortunately, the presentation of a dissection can be diabolical, leading to an initial misdiagnosis in more than 25% of patients. For type A dissections, surgical repair is essential because mortality rates approach 50% at 48 hours with expectant therapy alone. For type B dissections, medical management is successful in most patients, although a subset with complications or early dilation may benefit from newer endovascular techniques. The goal of this review is to summarize the diagnostic algorithm, initial therapeutic options, and long-term management regimen that offer patients with an acute aortic dissection the best chance for short-term and long-term survival. There is an emphasis on the specific practical approach that is applied at Washington University to patients who present with an aortic dissection.